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The CDC is reporting the first ever United States confirmed case of MERS-CoV. The individual, a health care worker who travelled back from Saudi Arabia on April 24th, initially presented to an emergency department in Indiana on April 27th with complaints of fever, cough and shortness of breath. Given his travel history a sample was taken and sent to the CDC for evaluation. On Friday, May 2nd, the CDC confirmed that the patient had MERS-CoV.

What is MERS-CoVMERS-CoV is a novel coronavirus that can lead to severe respiratory illness in humans. Partial genomic sequences and receptor usage suggests that bats may have served as the original MERS-CoV host species. There has been speculation that there may have been a intermediate host such as camels and goats however this has not been proven (Raj et al, 2014).

How is the virus spreadClusters of human to human transmission have been reported in multiple countries throughout Europe and the Arabian Peninsula. However, these outbreaks have not shown sustained human to human transmission (Raj et al, 2014).

In 2013, in a hospital located in an eastern province of Saudi Arabia, a total of 21 of 23 reported cases were acquired by person-person transmission in hemodialysis units, ICUs or in-patient units in three separate health care facilities. From these cases there were approximately 200 health care worker (HCW) contacts, 2 of which developed laboratory confirmed disease (Assiri et al, 2013). In another case of 11 MERS-CoV ICU patients, 520 HCW’s were exposed but only 4 (1%) tested positive (Arabi et al, 2014). While there are many variables that could affect the transmission of MERS-CoV, it does not appear that spread of the virus readily occurs from patient to HCW.While this data suggests that human to human transmission is possible, it is not clear if comorbidities increase the risk of acquiring the disease. For example, patients with diabetes and chronic renal failure seemed to be at increased risk of severe infection. However, it is not clear whether these conditions are a risk factor for infection or simply predisposed the patients to be preferentially exposed (Perlman et al, 2013). These are important questions that need to be addressed before one can fully appreciate the nature of MERS-CoV transmission. Case Definition

Fever (≥ 38º C) and pneumonia or acute respiratory distress syndrome

and either

History of travel from countries near the Arabian Peninsula w/ 14 days of onset

or

Close contact with a symptomatic traveler who developed fever and acute respiratory illness w/in 14 days after traveling from countries in or near the Arabian Peninsula.

Impact on Emergency MedicineWith less than 500 confirmed cases globally and an unknown prevalence of disease the current impact of this disease is unclear. While the mortality of known cases is high- 401 confirmed cases in 6 countries, 93 people (23%) have died- there is not a surveillance program or case definition that captures less severe cases. This leaves the true severity of the disease ill defined.

Regardless, it is important that emergency medicine physician be vigilant. Thus far all confirmed cases have originated in patients who recently travelled from the Arabian Peninsula (Bahrain, Iraq, Iran, Israel, Jordan, Kuwait, Lebanon, Oman, Palestinian territories, Qatar, Saudi Arabia, Syria, the United Arab Emirates and Yemen). Therefore, obtaining a travel history in patients with signs and symptoms of upper respiratory tract infection is essential to early identification of at risk patients.

In patients that meet the above case definition the CDC recommends evaluating all causes of community acquired pneumonia while working up MERS-CoV. The health care provider should notify their local health departments as well as the CDC. This short form can be completed by any provider and faxed to the CDC.

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Las Vegas EM FOAM Blog

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